Health inspection·June 6, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of a clinical note dated 5/22/23 at 5:13 a.m., completed by LVN F, indicated Res. (#1) was up most of the night shift wandering the halls, res would go back to room and lay down but get back up 15 minutes later and wander again. Res. (Resident) At some point during this shift (10p.m. to 6 p.m.) took off her wander guard somehow nurse searched the room for it and how she got it off, but nothing was found even the missing Wander guard anklet. Nurse applied new Wander guard to resident's left ankle and explained to resident she has to keep it on. Nurse put in nurses report sheet to keep monitoring res. wander guard. Record review of a clinical noted dated 5/22/2023 at 9:14 p.m., completed by LVN E indicated while SN (skilled nurse) was charting at the nurses's station, family member informed nurse that she could not find her mother. Asked family member who was she visiting, and family member stated Resident #1. Immediately went to Resident room to check if Resident was in her restroom or any other restrooms located in the back of west wing. Nurse did not see patient in any bathrooms nor was the alarm system sounding d/t (due to) Resident has a wanderguard to right ankle and nurse checked for placement and function of wanderguard at the beginning of shift when Resident was sitting in chair across from nurse station with her former roommate. Immediately assigned all staff on west and east wing to check all bathrooms and closets d/t possible missing resident .At 6:22 p.m., informed by [facility] staff that resident was located. Nurse when to scene where resident was found along with police arriving to scen as well. Resident was located at the corner store next door in the woods. Nurse able to d a decent head to toe assessment and therapist at the scene along with CNAs. Resident was able to perfrom full [range of motion] and denied pain or discomfort. Resdient brought back to facility in wheelchair .Nurse checked resident vital signs 158/85 pulse 85 [respiratory rate] 20 [oxygen saturation] 96%. Small skin tear noted to right knee .1x.1 [cm] and very small scrathces on right ankle. Upon assessment nurse noted wanderguard was not on resident right ankle. Asked resident how did she remove her wanderguard/resident state she used scissors. Nurse asked resident where did she get scissors from/resident did not answer because a family member state she does not have to answer any of those questions and also state she is not to blame .Informed by supervisor per facility policy resident is to be sent to [emergency room] for evaluation .Resident sent to [emergency room] with [emergency medical personnel] .at approximately 7:20 p.m .When resident and family left/supervisor found wanderguard in former resident room across the hall in trash can which appears to be a clean cut removed from her ankle. Asked former roommate if we can use her scissors. Resident stated sure just make sure you return them. Long scissors with black and blue handle removed from resident room . Record review of a clinical note dated 5/22/2023 at 10:36 p.m., completed by LVN E, indicated Resident #1 was redirected often due to going to the front and back door several times, setting of the alarm . The LVN indicated to check for the wanderguard bracelet because she somehow removed the current one. Record review of Resident #1's records dated May 2023 indicated there was no documentation of Resident #1's location every 30 minutes on each shift. During an observation on 5/24/23 at 11:15 a.m., the Investigator observed highway where Resident #1 walked toward had a moderate amount of traffic. The speed limit in front of the facility was 45 mph. During an observation on 5/24/2023 at 12:12 p.m. of a facility video dated 5/22/2023 at 6:02 p.m., Resident #1 was observed walking out of the facility's back door on the west hall. She walked in the parking lot toward the front of the facility. When she got to the last parking spot closest to a busy highway in front of the facility, she turned left toward the gas station next to the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few There was a small, tapered ditch, knee deep, she walked through. As Resident #1 reached the front of the store and stepped out of site (6:04 p.m.), her family pulled in the parking spot closest to the highway. During an observation on 5/24/2023 at 12:50 p.m. of a video of the gas station next to the facility, provided by Resident #1's family member, dated 5/22/2023 at 5:40 p.m., indicated Resident #1 was seen ambulating in the parking lot of the gas station. She was seen waving to an unknown female getting into a pickup. The Resident kept walking toward the tree line and disappeared. During an interview on 5/24/2023 at 10:20 a.m., the DON said Resident #1 had a wanderguard bracelet on her ankle due to wandering. She said on 5/22/2023, the day Resident #1 eloped she kept setting off the alarm by trying to sit in the front lobby by the window. She said the Resident was telling staff If you just cut this thing off (referring to the wanderguard bracelet on her ankle), I could go outside. The DON said the resident mostly stayed in the common areas during the day but ate her meals in her room. She said Resident #1 was not placed on 1:1 supervision. The DON said Resident #1 had her dinner tray picked up between 5:45 p.m. and 5:50 p.m. She knew it was around that time because the CNA's shift ended at 6:00 p.m. She said CNA C clocked out at 5:58 p.m. and went out the door near Resident #1's room. CNA C told the DON Resident #1 was in her room at that time. She said the Resident was on the other side of her bed near the window and did not notice if the Resident had the bracelet on her ankle. The DON said they determined Resident #1's ex-roommate gave her scissors to cut the bracelet off. The bracelet was found in the ex-roommate's garbage can. During an interview on 5/24/23 at 11:09 a.m., OT D said on 5/22/2023 she was told Resident #1 was missing and started looking outside. She said she followed the tree line behind the facility to the gas station next door. She said when she got just past the gas pumps she heard help me. She found Resident #1 sitting on the ground just behind the trees. She tried to get the Resident up, but the Resident was not able to stay standing. OT B said she had forgotten to grab her phone. She told Resident #1 to stay where she was while she went to get assistance. She said the family was already at the facility and assisted Resident #1 into the wheelchair and took her back to the facility. During an interview on 5/25/2023 at 8:39 a.m., the ED said staff had been educated on door checks, alert administration if there was a concern a resident might cut off their wanderguard bracelet. She said they were scheduled to have a QAPI meeting on 7/2/2023. RN A told the ED at that time she could do an emergency QAPI meeting to address the elopement issue. The ADON said, at that time, elopement risks were completed on admission, quarterly and significant change in condition. She said she completed an elopement risk assessment on Resident #1 the day (5/23/2023) she left the facility. The ADON said Resident #1's former roommate had scissors and they found the wanderguard bracelet in her trashcan on 5/22/2023, so they assumed that was how she got the bracelet off. During an interview on 5/25/2023 at 11:28 a.m., CNA B said she had not been told to increase monitoring of Resident #1. She was not aware she had taken her wanderguard bracelet off prior to the elopement on 5/22/2023. She said she knew Resident #1 would try to leave because she had been going to the door more. During an interview on 5/25/2023 at 11:58 a.m., the DON said she had not been aware of the increased exit seeking behaviors of Resident #1 until she read the clinical notes after the elopement. During an interview on 5/25/2023 at 12:27 p.m. LVN E said they had been monitoring Resident #1 because her Seroquel (used for behaviors) had been decreased. She said when they found Resident #1 on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 5/22/2023, the Resident said she had cut off her bracelet with scissors. She said they found the wanderguard bracelet in her old roommate's trash on 5/22/2023. During an interview on 5/25/2023 at 12:41 p.m., CNA C said she was not told to increase monitoring of Resident #1 prior to her eloping. She said she clocked out at 5:58 p.m. and went out the back door by Resident #1's room. She said the Resident was sitting in her chair by the window and could not see her feet. She said she waved to the Resident and left. Record review of the facility's Patient Care Management System 3 Accidents/Incidents dated May 2016 indicated A Patient requiring the use of a Wandering Prevention Device must be assessed to ensure that the device is on the patient and working. The device must be tested using a Signaling Device Tester provided by the maker of the Wandering Prevention Device. The test will be documented daily, and visual verification that the device is in place on the Patient will be documented every shift. Record review of the facility's Wandering Patients policy revised February 2020 indicated Patients that are determined to be wanderers will receive the following interventions: Wandering behavior will be care planned with appropriate interventions documented, Wandering Patients will be counseled by intervening staff and redirected to appropriate Patient care areas . Record review of the facility's undated elopement protocol indicated ED or DON must be notified when a resident has increased behaviors. The ED and DON were notified of the IJ on 5/25/2023 at 4:55 p.m., the IJ template for Accident/Hazard and Supervision was given to the ED and DON. The findings were read to them and explained the process and a POR was requested. The following POR was submitted and accepted on 5/26/2023 at 10:31 a.m. Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to Accidents and Supervision called at 4:55 pm. The facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents. Residents that can be affected are those with imminent elopement risk assessments. At this time, the facility does not have any residents who could be affected. Systematic Approach: 1. Assessment -The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 05/25/22 at 5:08 pm. -An emergency QAPI meeting was held on 5/25/2023. -All residents will have an elopement risk assessment updated by the Director of Nurses, Assistant Director of Nurses and/or Patient Care Coordinator on 5/25/2023 to identify any current patients that are at imminent risk for elopement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few After completion of elopement assessments, no other residents were found to be at imminent risk of elopement. The assessment includes the following information: The assessment was to determine if a resident was an imminent risk for elopement. The resident will have to intentionally or unintentionally attempt to leave the community or verbalize a plan to elope the community to be documented in the elopement assessment as an imminent risk for elopement. Who will be responsible: Nurse Managers. Who Will monitor: Executive Director/Director of Nursing. -Beginning 5/25/2023, elopement assessments will be completed upon admission, condition change, and quarterly by the charge nurse and/or nurse managers, and for any resident that triggers an imminent risk for elopement, the elopement response protocol will be initiated. The ED and DON will monitor for compliance daily by running an audit of the elopement assessments. Audits will be completed weekly for 3 months until 8/25/2023 and then monthly on an ongoing basis. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing -Beginning 5/25/2023, wanderguard placement and working order will be checked for working order every shift by the charge nurse or nurse managers. The wanderguard placement and working orders will be documented in the EMR system. -Beginning 5/25/2023, the wanderguard system will be checked for working order every day by the maintenance director, Manager on Duty or Executive Director. The working order of the wanderguard system will be documented on the Daily Door Alarms, Wandering Systems and Storage Areas Log. -Beginning 5/25/23, any resident who triggers an imminent risk of elopement, meaning the resident intentionally or unintentionally attempts to leave the community or verbalize a plan to elope the community, will have notification placed in the elopement binder by the nurse manager and monitored by clinical staff in accordance with the elopement response protocolFacility staff will conduct thorough rounds of facility grounds. If resident is not found within 15 minutes charge nurse will call the ED immediately. ED will call family, police and notify physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 ED will notify HHSC of incident. Level of Harm - Immediate jeopardy to resident health or safety - Residents Affected - Few - Facility staff will continue to search for resident until found. Once resident is found, a nurse will do a head-to-toe assessment and provide care accordingly. In addition, the physician and responsible party will be notified of the results. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing All staff were educated to notify the Executive Director or nursing management immediately upon elopement or verbalization of an elopement plan of a resident. This education was provided on 5/25/2023. This education was provided by the Executive Director, Director of Nursing and Assistant Director of Nursing. Staff will not be allowed to begin their shift until the education has been completed. Until alternative and or safe living arrangements are made the resident will be placed on one-on-one supervision with facility staff. The resident's picture and face sheet will be placed in an elopement binder. Resident care plans will also be updated. The Director of Nursing and/or Nurse Managers will monitor weekly for compliance by completing an audit of the elopement assessments and the elopement binders. Audits will be completed weekly for 3 months until 8/25/2023 and then monthly on an ongoing basis. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing No items were found available that could assist residents at risk of wandering in removing their wanderguards on 5/25/2023. This search was conducted by the Executive Director and nursing managers. 2. In-Services Clinical staff were in-serviced on the elopement by the Director of Nursing and/or Nurse Managers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety All new clinical staff will receive the Elopement in service as part of the onboarding orientation process prior to being assigned and providing care to residents. No clinical staff member will be allowed to work in the facility until the above required in-services are completed. The in-service with all staff will be completed by 5/26/2023. All staff were in-serviced by 8am on 5/26/2023. Who will be responsible: Nurse Managers Residents Affected - Few Who Will monitor: Executive Director/Director of Nursing Shift to Shift reporting process will be as follows: 1. As part of shift to shift report the charge nurse will print the census to identify residents who are on leave and not in the facility. 2. At shift change, 6 a.m., 2 p.m., 10 p.m.- the oncoming nurse will conduct walking rounds with the outgoing nurse and will account for each patient on the census. 3. At shift change, 6 a.m., 6 p.m.- Certified Nurse Aides must conduct walking rounds and visually account for each resident. All new clinical staff will receive the elopement in service as part of the onboarding process prior to being assigned and providing care to residents on the floor by the Director of Nursing and/or Nurse Manager. All nurses and CNAs will be in-serviced on the shift-to-shift report process by the Executive Director, Director of Nursing or Assistant Director of Nursing by 5/26/23 at 8:00 a.m. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing All staff in-service on changes in condition including increased wandering and elopement risk. Nurses will notify the Director of Nursing or nurse manager of changes in the condition of a resident. This in-service will be completed by 12 noon 5/25/2023 by the Director of Nursing and nurse managers. 3. Implementation of anti-elopement process (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Beginning 5/25/2023 the Certified Nurse Aides and Nurses are performing every 2-hour body checks which means conduct walking rounds and visually account for each resident, every shift and notifying the Executive Director and Director of Nursing immediately within 15 minutes per elopement protocol if a resident cannot be located. - Residents Affected - Few In-servicing will be completed with the charge nurses and CNAs by the Executive Director, Director of Nursing or Assistant Director of Nurses by 5/26/2023. All nurses and CNAs will be in-serviced on the shift-to-shift report process by 5/26/2023 at 8 a.m. Who will be responsible: Nurse Managers Who Will monitor: Executive Director/Director of Nursing 4. Monitoring Starting 5/25/23 the Executive Director, Director of nursing and/or Nurse Managers will receive in hand, the resident monitoring/every 2- hour body check documentation at the end of each shift for the first 72 hours, each day for one week, then weekly for 4 weeks. This monitoring will include checking that each resident with a wander guard has the device in place and in working condition. The Regional Director of Clinical Services will review the documentation each week for compliance. Beginning 5/25/2023 no clinical staff will be allowed to work until the required in servicing has been completed. 5. Quality Starting 5/25/2023 and ongoing monthly all concerns regarding adequately supervising residents will be taken to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. The Executive Director will monitor for compliance. Starting 5/25/2023 and ongoing monthly all concerns regarding completing the elopement assessments and residents at risk of elopement will be taken to the Quality Assurance Committee for analysis and recommendations with input from the Medical Director going forward. The Executive Director will monitor for compliance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mill Creek 1105 W Hwy 418 Silsbee, TX 77656 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 - Level of Harm - Immediate jeopardy to resident health or safety Starting 5/25/2023 and ongoing monthly the Executive Director will monitor daily to ensure compliance for four weeks and will review at the next Quality assurance meeting. Monitoring of POR: Residents Affected - Few On 5/26/2023 at 5:35 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to lift the immediacy by: Record review of the in services dated 5/26/2023 related to elopement protocol, executive director notification, change of condition with focus on wandering and behaviors, room rounds every 2 hours, every 2 hours body checks for wanderguard bracelets, and walking rounds at shift change. During interviews of the ED, RN A, 4 LVNs, 6 CNAs, the DM, and the AD the retraining related to elopement protocol, executive director notification, change of condition with focus on wandering and behaviors, room rounds every 2 hours, every 2 hours body checks for wanderguard bracelets, and walking rounds at shift change was confirmed. During observations on 5/26/2023 from 2:25 p.m. to 4:00 p.m. indicated staff were making rounds and monitoring residents with wanderguard bracelets. The ED was informed the IJ was lifted on 5/26/2023 at 4:35 p.m., however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an exit conference on 6/6/2023 at 3:00 p.m. the ED was asked for any additional information related to accidents/supervision. No additional information was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675338 If continuation sheet Page 9 of 9